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The International Arabic Journal


of Antimicrobial Agents ISSN 2174-9094

Streptococcus pneumoniae
carriage, resistance and serotypes
among Jordanian children from
Wadi Al Seer District, Jordan

2014
Vol. 4 No. 2:5
doi: 10.3823/752

Adnan Al-Lahham1,
Mark van der Linden2
1School of Applied Medical Sciences,
German Jordanian University,
11180-Amman, Jordan.
2 National Reference Center for
Streptococci, Department of Medical
Microbiology, University Hospital
(RWTH), Aachen, Germany.

Corresponding author:
Adnan Al-Lahham1

Abstract

 adnan.lahham@gju.edu.jo

Objectives: Detection of carriage rate of Streptococcus pneumoniae


from children in Wadi Al Seer district, Jordan.
Methods: Nasopharyngeal were collected from 118 children aged between one to 50 months. S. pneumoniae isolates were analysed for
resistance, serotyping and macrolide resistant genotypes and phenotypes.
Results: Carriage rate was 55.1% (n= 65/118). Resistance rate was
as follows: Penicillin (80%), trimethoprim-sulfamethoxazole (73.8%),
erythromycin (61.5%), tetracycline (53.8%) and clindamycin (33.8%),
Multidrug resistant isolates were 56.9%. (MIC50 & MIC90 g/ml) were
as follows: Penicillin (0.5,2), erythromycin (2, >=32), clindamycin (0.06,
>=32), trimethoprim-sulfamethoxazole (4, >=32). M-Phenotypes
(45%), iMLSB (2.5%) and cMLSB (52.5%) with genotypes erm(B) 55%,
and mef(A) 45%. Common serotypes were: 19F (18.5%), 6B (16.9%),
23F (12.3%), 35B (6.2%). Coverage of PCV7, PCV10 and PCV13 was
52.3%, 52.3% and 58.5%, respectively.
Conclusions: High rates of S. pneumoniae carriage and drug resistance
is a potential serious risk to increase pneumococcal invasive and non
invasive infections in Jordanian children.
Keywords: Streptococcus pneumoniae, Resistance, Colonization, Jordan.

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The International Arabic Journal of Antimicrobial Agents


ISSN 2174-9094

Introduction
Streptococcus pneumoniae is a leading cause of
bacterial pneumonia, meningitis, bacteraemia, otitis media, and sinusitis and continues to be a significant cause of morbidity and mortality in humans
[1]. The worldwide increase in antibiotic resistance
in these species has become a serious problem
within the last twenty years [2]. S. pneumoniae
was given the name as the forgotten killer in children in 2008 by the WHO [3], which accounts for
more than one third of acute bacterial sinusitis and
more than one half of community-acquired bacterial pneumonia [4]. It remains a major cause of
childhood morbidity and mortality, where at least
1.2 million children die of pneumococcal infections
each year as stated by the WHO in 2007 and 70%
of them in Africa and southeast Asia; mostly in
developing countries [5].
Antibiotic treatment of invasive disease has been
widely countered by the increasing emergence of
resistance in many parts of the world in the recent
years. Resistance to beta-lactam, macrolides, tetracycline and trimethoprim-sulfamethoxazole were
reported [6]. However, the resistance pattern varied
greatly from country to country [7]. This emphasises
the importance of local data in determining the appropriate antibiotic therapy.
S. pneumoniae is a common colonizing bacterium
in the respiratory tract, mostly symptom less; however it can progress to respiratory or even systemic
disease. An important feature is that pneumococcal
disease will not occur without preceding nasopharyngeal colonization with the homologous strain, so
pneumococcal carriage is believed to be an important source of horizontal spread of this pathogen
within the community [8]. Increased prevalence of
S. pneumoniae in healthy childrens nasopharynx
reflects a potential risk to develop more frequently
respiratory infections in the community [9,10].

2014
Vol. 4 No. 2:5
doi: 10.3823/752

There is only one old Jordanian study published in


2000 which has reported on the antimicrobial susceptibility pattern of S. pneumoniae isolates from
various clinical specimens, and this study showed
that 56% of the isolates were penicillin resistant
[11], however, recent data about prevalence of antimicrobial susceptibility pattern of this organism in
children population are not available. Furthermore, it
is essential to determine the distribution of S. pneumoniae serotypes among children in each country in
order to address the actual value of using available
commercial vaccines to minimize the pneumococcal
infections [12].

Material and Methods


Study design
One hundred and eighteen children aged 1 month to
50 months were chosen randomly from the Maternity
Health Center of Wadi Al Seer district in Amman to be
included in this during 2009. The study has involved
7 smaller neighborhoods. The recruitment phase
started by sending letters explaining the purpose of
the study and containing consent form and questionnaire regarding potential risk factors for the carriage
of S. pneumoniae were sent to parents. Only children
whose parents consented to participate were enrolled
in the study. Also, at the time of the study, all investigated children were admitted to the Maternity Health
Care Center for the periodic checkups, and these were
not vaccinated with the 7 valent pneumococcal conjugate vaccine (PCV7, Pfizer Inc., USA).

Specimen collection and transport


Sterile nasopharyngeal and throat swabs pre-moistened with sterile water were taken by the medical
doctor from each child [13]. The swabs were transported in ice box to the laboratory within 4 hours
for culture.
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2014

The International Arabic Journal of Antimicrobial Agents

Vol. 4 No. 2:5


doi: 10.3823/752

ISSN 2174-9094

Bacterial identification
In the laboratory, each swab specimen was mixed
thoroughly using a vortex mixer before inoculation onto Colombia blood agar base (Oxoid, UK)
supplemented with 5% sheep blood (Oxoid, UK).
Plates were incubated at 37C for 24h-48h with 5%
CO2. S. pneumoniae colonies were selected based
on colony morphology, a-haemolysis, susceptibility
to optochin, and bile solubility, then pneumococcal colonies were purified and stored at -20C for
further work [14].

Susceptibility testing
Minimal inhibitory concentration (MIC) testing was
performed using the broth microdilution method as
recommended by the Clinical Laboratory Standards
Institute (CLSI) [15]. S. pneumoniae ATCC 49619
was used as a control strain.

Serum Institute of Copenhagen-Denmark [16]. This


part of work was performed at the National Reference Center for Streptococci in Germany.

Analysis of resistance determinants


PCR of macrolide resistance determinants was performed as described previously [17]. For the classical
detection of erm(B) and mef(A) the following primers were used: erm(B) 5-CGAGTGAAAAAGTACTCAACC-3 (362-382) and 5-GGCGTGTTTCATTGCTTGATG-3 (978-958), mef(A) 5-AGTATCATTAATCACTAGTGC-3 (57-77) and 5-TAATAGATGCAATCACAGC-3` (550-532). The macrolide resistance phenotype was determined on the basis of
the pattern of susceptibility to MLSB (macrolidelincosamide-streptogramin B) [18].

Results

Serotyping

S. pneumoniae carriage rate

Serotypes were done by the Neufeld Quellung reaction method with the available antisera from Statens

A total of 65/118 children (55.1%) were found to


carry S. pneumoniae in the nasopharynx (Table 1).

Table 1. D
 istribution of carriage rates in different age groups of the children in association
with the coverage of pneumococcal conjugate vaccines*
Age (Years)

No. of carriers**/ Total


No. of children (%)

coverage 7v PCV
(%)

coverage 10v PCV


(%)

coverage 13v PCV


(%)

<= 1 year

42/ 65 (64.6%)

20/42 (47.6)

20/42 (47.6)

22/42 (52.4)

>1- 2

16/ 31 (51.6%)

10/ 16 (62.5)

10/ 16 (62.5)

11/ 16 (68.8)

>2- 3

4/ 13 (30.8%)

2/4 (50)

2/4 (50)

3/4 (75)

>3 years- 50 months

3/9 (33.3%)

2/3 (66.6)

2/3 (66.6)

2/3 (66.6)

Birth - 2 years

58/ 96 (60.4%)

30/58 (51.7)

30/58 (51.7)

33/58 (56.9)

(Total ) 0- 50 months

65/118 (55.1%)

34/65 (52.3)

34/65 (52.3)

38/65 (58.5)

* A total of 51.2% the examined children showed upper respiratory tract infection, and 27.1% were previously treated with antibiotics
** S. pneumoniae was isolated at the same time from 12% of both throat and nasopharynx swab specimens.

Under License of Creative Commons Attribution 3.0 License

2014

The International Arabic Journal of Antimicrobial Agents

Vol. 4 No. 2:5


doi: 10.3823/752

ISSN 2174-9094

The mean age of children was 13.4 months, and


the range of age was 1 to 50 months. The children
included 51.7% males and 48.3% females. A total
of 31/118 (27.1%) have been treated previously with
antibiotics.

Antimicrobial susceptibility
The percentage of resistance among S. pneumoniae
was as follows: Penicillin G (80%), trimethoprimsulfamethoxazole (73.8%), tetracycline (53.8%),
erythromycin (61.5%) and clindamycin (33.8%).
Vancomycin, amoxicillin, cefotaxime, levofloxacin
and telithromycin showed no resistance. Minimal
inhibitory concentrations of S. pneumoniae isolates
(MIC50, MIC90 g/ml) were as follows: Penicillin
(0.5, 2), erythromycin (2, >=32), clindamycin (0.06,
>=32), trimethoprim-sulfamethoxazole (4, >=32), tetracycline (16, 32), and levofloxacin (0.5, 1) (Table 2). A
total of 37 isolates (56.9%) were Multidrug resistant
and were belonged mostly to serotypes available in

the pneumococcal conjugate vaccines (6B, 6A, 14,


19A, 19F and 23F) (Table 4).

Macrolide resistant pheno- and genotypes


Resistance to erythromycin A accounted to 61.5%
(n= 40) of S. pneumoniae isolates. Of these two
different phenotypes of macrolide resistance were
found. MLSB constitutive phenotype accounted to
52.5% of isolates (n= 21), and 45% (18 isolates) had
the M-phenotype, and 2.5% (1 isolate) was inducible MLSB (Table 3). It was observed that penicillin
resistant strains had higher MICs towards macrolide
drug. Macrolide resistant genotypes were divided in
ermB (55%; 22 isolates) and mefA (45%; 18 isolates)
(Table 3).

Serotyping
The most common serotypes indicated were the
following: 19F (18.5%), 6B (16.9%), 23F (12.3%),

Table 2. Ranges of MIC50, MIC90,and antibiotic resistance patterns of 65 isolates of S. pneumoniae

Antibiotic

MIC range (n=65)

(n) % resistance (I, R)

% Sensitive

MIC50

MIC90

Penicillin G

0.016- 8

(52) 80

20

0,5

Erythromycin A

0.06- >=32

(40) 61.5

38.5

>=32

Clindamycin

0.06- >=32

(22) 33.8

66.8

0,06

>=32

Sulfameth. Trimeth.

0.06- >=32

(48) 73.8

26.2

>=32

Tetracycline

0.25-32

(35) 53.8

46.2

16

32

Vancomycin

<=2

(0) 0

100

<=2

<=2

Levofloxacin

0.5-2

(0) 0

100

0,5

Amoxicillin

0.016- 1

(0) 0

100

0.03

0.06

Cefotaxime

0.016- 0.5

(0) 0

100

0.016

0.03

Telithromycin

0.016- 0.5

(0) 0

100

0.016

0.03

 reakpoints (I, R) according to CLSI: Penicillin G: (0.11 g/ml, 2 g/ml); cefotaxime: (2 g/ml, 4 g/ml); erythromycin A
B
(0.5 g/ml, 1 g/ml); clindamycin :(0.5 g/ml, 1 g/ml); tetracycline: (4 g/ml 8 g/ml); trimethoprim-sulfamethoxazole:
(1/19-2/38 g/ml, 4/76 g/ml); and all isolates were susceptible for vancomycinat MIC 1 g/ml.

This article is available from: www.iajaa.org / www.medbrary.com

2014

The International Arabic Journal of Antimicrobial Agents

Vol. 4 No. 2:5


doi: 10.3823/752

ISSN 2174-9094

35B (6.2%), 11A, NT and 15A (4.6%) each isolated,


followed by serotypes 14, 34, 23A, 6A, and 19A
with 3.1% each isolated (Table 3).

Coverage of the pneumococcal


conjugate vaccines

PCV7, PCV10 and PCV13 was 52.3%, 52.3% and


58.5%, respectively. Although the highest coverage
of the 7v-PCV (66.6%) was observed among infants
aged between 2 to 3 years of age but the total
number of these children was 13 in the study. In
children below one year of age (n=65), coverage of
the PCV7 was 64.6% (Table 1).

The total coverage of the PCV7 among all children


with positive isolates was (55.1%). Coverage of
Table 3. Distribution of S. pneumoniae serotypes and macrolide resistant pheno-genotypes among examined children
Serotype
And
Phenogenotype

19F

6B

23F

Number

12

11

12.3

6.1

4.6

4.6

Percentage 18.5 16.9

35B 11A 15A NT

14

34

6A 23A 19A *Others M-Ph

4.6 3.1 3.1 3.1

cMLSB

iMLSB

ermB

mefA

11

18

21

22

18

3.1

3.1

16.9

45

52.5

2.5

55

45

* Other serotypes; 33F, 15B, 15F, 16F, 17F, 18A, 22F, 33A, 35A, 7B, and 9V each of these serotypes was detected one time with (1.5%)

Table 4. Resistance patterns according to the serotype of S. pneumoniae isolates

Serotype

No. ( % )
of isolates

6B

Isolates with resistant serotypes to antibiotics


PEN
n (%)

FUR
n (%)

ERY
n (%)

CLI
n (%)

SXT
n (%)

TET
n (%)

Multiresistant
isolates
n (%)

11 (16.9)

10 (90.9)

7 (63.6)

8 (72.7)

8 (72.7)

10 (90.9)

7 (63.6)

7 (63.6)

9V

1 (1.5)

1 (100)

1 (100)

1 (100)

0 (0)

1 (100)

1 (100)

1 (100)

14

2 (3.1)

2 (100)

2 (100)

2 (100)

2 (100)

2 (100)

2 (100)

2 (100)

19F

12 (18.5)

11 (91.7)

11 (91.7)

10 (15.4)

5 (7.7)

12 (100)

9 (75)

5 (7.7)

23F

8 (12.3)

8 (100)

7 (87.5)

4 (50)

0 (0)

8 (100)

4 (50)

4 (50)

19A

2 (3.1)

2 (100)

1 (50%)

2 (100)

1 (50%)

1 (50%)

0 (0)

2 (100)

6A

2 (3.1)

2 (100)

1(50%)

2 (100)

2 (100)

1(50%)

2 (100)

2 (100)

aOthers

27 (41.5)

16 (59.3)

9 (33.3)

11 (40.7)

4 (14.8)

13 (48.1)

9 (33.3)

14 (14.8)

Total

65

52 (80)

39 (60)

40 (61.5)

22 (33.8)

48 (73.8)

34 (52.3)

37 (56.9)

aOthers:

Serotypes not included in the 7 valent pneumococcal conjugate vaccine. Serotypes 4 and 18C were not found in this study.
Abbreviations: PEN, Penicillin; FUR, Cefuroxime; ERY, Erythromycin; CLI, Clindamycin; SXT, Sulfamethoxazole-Trimethoprim; TET, Tetracyclin

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The International Arabic Journal of Antimicrobial Agents


ISSN 2174-9094

DISCUSSION
To our knowledge, this is the first data from Jordan which describe the pneumococcal serotypes
colonized in the pediatric population of one district in Jordan. Nasopharynx is the usual source of
pneumococci for studying the carriage rate [19].
This study has demonstrated that carriage rate of
S. pneumoniae among children in Jordan is high
(55.1%) compared to the study reported by Lee et
al., for carriage rate of pneumococci in 4963 Asian
children aged below 5 years from 11 countries [ 20
]. The results of the study investigated showed the
following rates: Philippines (32.6%), China (37.5%),
India (43.2%) and Thailand (40.6%), but lower rates
in Taiwan (15.3%) and Saudi Arabia (9.0%). Similar
carriage rates were obtained from Brazil (55%) [12],
Guatemala (59.1%) [21], and in Kampala Uganda
(62%) [22]. The high rate of pneumococci colonization can be due to different factors such as history of sicknesses, immune deficiency, viral infections and history of antibiotic consumption before
attending the Daily Care Center (DCC) as the case
with our investigated children. Since 51.2% of our
examined children had suffered of upper respiratory tract infections before admission to the DCC,
and data taken from childrens medical records of
the DCC showed that 27.1% had a history of antibiotic consumption prior to their visits to the DCC,
which could be contributed for selection of resistant strains [18]. The differences in carriage rates
worldwide were related to certain socio-economic
conditions including housing, access to health care,
poor hygiene, family size, overcrowded living conditions, day-care contact, and number of siblings
[23]. Previous studies reported the attendance of
day care as a main factor causing the increase of
the carriage rate of S. pneumoniae [24]. Continuous
surveillance of the susceptibility patterns of S. pneumoniae becomes increasingly important, because
of the increasing emergence of antibiotic-resistant
strains worldwide [25].

2014
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doi: 10.3823/752

This study suggests that prior antibiotic use is not


only an important risk factor for an increased S.
pneumoniae carriage but may be also considered a
risk factor for carriage of multiple-resistant strains
of pneumococci. The antibiotics susceptibility of the
S. pneumoniae isolated from our childrens nasopharynx reflected alarming rates of resistance to
penicillin, erythromycin and occurrence of multidrug-resistant isolates. Rates of antibiotic resistant
of S. pneumoniae isolates among our children were
higher than those clinical isolates from Singapore
and Sri Lanka but similar to Taiwan [20]. However,
our resistance rates resemble the rates reported in
some other Asian countries [26]. The high rates of
resistance to different classes of antibiotics in S.
pneumoniae in this study are presumably a consequence of antimicrobial consumption and its misuse within the Jordanian population [27]. Otoom
et al., (2002) reported that antibiotic prescriptions
in Jordan at different health centers ranged between 46.7% to 83.3%; and these rates are very
high compared to many other parts of the world
[28]. Local information on capsular types of S. pneumoniae causing disease in young children is highly
important to guide production of effective conjugate vaccine. Our results of S. pneumoniae serotyping showed that most prevalent serotype was 19F
(18.5%) followed by 6B (16.9%) then 23F (12.3%).
Similar serotyping results has been reported fromKuwait among S. pneumoniae isolates from children
(6B and 23F had a prevalence of 9%, and 19F accounted for 9.8%) [29]. A study by Marchisio et al.
(2002)in Italy, has found that S. pneumoniae carrier
rate was 8.6% and included the following serotypes
(3, 19F, 23F, 19A, 6B, and 14), and that most of
pneumococci isolates (69.4%) were resistant to one
or more antimicrobial classes [21]. Whereas children
aged 3-36 months attending day care centers in Belgium, had 21 % S. pneumoniae carriage rate and
the main serotypes were 19F (27.3%), 6B (20.2%),
23F (19.2%), 19A (10.1%), 6A (7.1%), 14 (5.1%) [19].
Prevenar, the 7-valent pneumococcal conjugate vacThis article is available from: www.iajaa.org / www.medbrary.com

The International Arabic Journal of Antimicrobial Agents


ISSN 2174-9094

cine (PCV7) and the new 13-valent pneumococcal


conjugate vaccine (PCV13) are used routinely in the
National Immunization Program of several industrialized nations. This study shows that both vaccines
are covering 52.3% and 58.5% of S. pneumoniae
serotypes distributed among our children, respectively. Around the world, the highest coverage for
PCV7 has been reported for the USA, Canada, and
Australia (8090%), followed by Europe and Africa
(7075%), whereas in Latin America and Asia the
coverage rates were 65% and 50%, respectively
[30]. Finally, our study was only performed in a small
group of children and one district of the capital Amman. We are aware that the carriage patterns may
vary between various communities and it is possible
that the serotype distribution and resistance patterns described here may not be representative to
the overall population of children in Jordan.

Acknowledgements
The authors thank the National Reference Center
for Streptococci in Aachen, Germany for the support with the reference strains and serotyping. The
study was supported by the deanship of scientific
research at the German Jordan University in Jordan.

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doi: 10.3823/752

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